How to Improve Diagnosis in the Emergency Department 

June 6, 2022

A 60-year-old woman presented to the local emergency department (ED) with complaints of a headache and a sudden onset of bilateral neck pain that began four days earlier. She denied any trauma, rated her pain as 9 out of 10 and described the pain as shooting up both sides of her neck. She also described dizziness with the onset of pain that had resolved. The ED physician noted that her neck was non-tender to palpitation and that she had pain when turning her head side to side. The ED physician diagnosed neck muscle spasm, prescribed Tramadol and instructed her to use a heating pad.

Late the next evening, the woman went to another ED with complaints of worsening headache and neck pain. The ED physician examined the woman, heard a right carotid artery bruit and noted meningismus. He performed a lumbar puncture (LP) to rule out meningitis that returned bloody cerebral spinal fluid that did not clear. Shortly after the LP, the woman had seizure-like activity and became unresponsive. She was intubated and a CT demonstrated a subarachnoid hemorrhage. She was transferred to a tertiary center where a large intracranial aneurysm arising from the distal vertebral artery was diagnosed. A neurosurgeon performed a coil intracranial embolization but unfortunately the woman remained unresponsive in the ICU for two weeks following surgery. Her family elected comfort care until she died a week later.

Her family filed a malpractice claim against the first ED physician and hospital alleging failure to diagnose and timely treat a vertebral aneurysm. The experts who reviewed the case were critical of the ED physician for failing to do a thorough exam and ruling out a vascular or neurologic cause of the woman’s sudden onset head and neck pain.

Diagnostic errors in the ED

An analysis of Constellation malpractice claims reveals that diagnostic errors in the ED are frequent, costly and often preventable. The top missed diagnoses in our ED claims are:

  • Vascular conditions: 28% (e.g., stroke, aneurysm, venous thromboembolism)
  • Infections: 21%
  • Fractures and dislocations: 14%
  • Cardiac events: 5%

Emergency medicine clinicians are cited as the clinician primarily responsible for care at the time of the alleged injury in 68% of claims, and radiology is the clinician primarily responsible in 17% of claims.

Breakdowns in the ED diagnostic process

We leveraged CRICO’s Diagnostic Process of Care Framework to map where along the process of care diagnostic breakdowns most commonly occurred. The majority of ED diagnostic error claims involve problems in the initial diagnostic assessment.

“Diagnostic errors occurring during initial assessments are frequently caused by cognitive biases, mental shortcuts and failure to use clinical diagnostic support tools.

Carolyn Anctil, MD, FACEP, Constellation Chief Medical Advisor
How to improve diagnosis in the ED

One way to assist clinicians during the initial assessment is with diagnostic support tools like checklists. Diagnostic checklists can:

  • Help ensure consistent care, decrease reliance on memory and prompt “must-not-miss” diagnoses
  • Counter the effects of fatigue, stress and high patient volume
  • Serve as a forced reflective “timeout”—a chance to pause, step back from the immediate problem and ensure a thorough analysis

Strategies to help clinicians manage vulnerabilities during the initial diagnostic assessment include:

  • Providing clinical decision support tools to help clinicians develop robust differential diagnosis lists
  • Building awareness among clinicians and within care teams about the pitfalls of cognitive biases and how checklists, templates and other forced checks can mitigate risk
  • Encouraging patients to become informed and part of the diagnostic team using tools like the Society to Improve Diagnosis in Medicine’s The Patient’s Toolkit for Diagnosis
  • Implementing ED clinician feedback regarding diagnostic accuracy (e.g., adverse event reports of delayed/missed diagnoses, patient complaints, autopsy reports, radiology overread discrepancies and peer discussion)

Sign in or register at and navigate to Risk Resources > Bundled Solutions > Preventing Diagnostic Error to access risk management guides and tools to help improve diagnostic processes in your organization.

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